FALLS CHURCH, Va. –
Did you know that we’re currently in
TRICARE Open Season? This is the time when eligible TRICARE beneficiaries can change or enroll in health plans for the upcoming year. But choosing a plan often means encountering a few unfamiliar
health care terms.
“Learning about health care can be intimidating for many beneficiaries because of all the different terms,” said Elan Green, chief of TRICARE Health Plan’s Member Benefits and Reimbursement Section at the Defense Health Agency. “However, it’s important you know the meaning of these health care terms and how they apply to your coverage and costs. This will help you better understand how your health plan works.”
Here are seven cost terms that you might encounter while researching your health plan for 2022.
1. Enrollment fee
An enrollment fee is an annual amount some beneficiaries must pay for TRICARE coverage. Who pays an enrollment fee each year? Active duty service members (ADSMs) and their family members have no enrollment fees. Retirees and their family members may be required to pay an enrollment fee. The individual enrollment fee is waived for TRICARE Prime enrollees who are entitled to Medicare Part B. Also, there are no enrollment fees for
TRICARE For Life (TFL).
2. Annual deductible
An
annual deductible is the amount you pay before cost-sharing starts. Your deductible resets each year. It applies to these plans:
A deductible also applies to
TRICARE Prime enrollees who choose to use the
point-of-service option.
For TFL, you only have to pay a TFL deductible when a service is covered by TRICARE and not by Medicare. Download the
TRICARE For Life Cost Matrix to see what Medicare and TRICARE pay.
3. Point-of-Service option
The
point-of-service option is for non-ADSMs enrolled in a TRICARE Prime plan. It allows you to see a TRICARE-authorized provider other than your primary care manager for any nonemergency services without a referral. Greater out-of-pocket expenses are associated with the point-of-service option. You’ll pay a deductible for outpatient claims. Deductible amounts don’t apply to inpatient claims. You’ll also pay cost-shares for inpatient and outpatient claims. This will be 50% of the
TRICARE-allowable charge after the deductible has been met. Point-of-service fees don’t apply toward your catastrophic cap.
The point-of-service option doesn’t apply to TRICARE Select or any other plan except TRICARE Prime.
4. Cost-share
You should also pay attention to
cost-shares. A cost-share is the percentage of the total cost of a covered health care service that you pay after your annual deductible is met. Sometimes you may have more than one cost-share, depending on the type of care you receive. An example of this would be if you see different doctors on the same day. Cost-shares don’t apply to ADSMs.
5. Copayment
A
copayment is a fixed dollar amount (for example, $30) that you pay for a covered service or prescription. This is different from a cost-share, which is the percentage of the total cost (for example, 25%). Copayments depend on your TRICARE plan, beneficiary category,
beneficiary group, the type of service you receive, and whether the service is provided by a TRICARE-authorized network provider.
Copayments don’t apply to ADSMs, who pay no out-of-pocket costs. Active duty family members enrolled in a TRICARE Prime plan also don’t have copayments unless using the point-of-service option or filling a prescription outside of a
military pharmacy.
6. Premium
A premium is the amount you pay to maintain your TRICARE coverage. The following plans have monthly premiums:
TRICARE Reserve Select,
TRICARE Retired Reserve, and
TRICARE Young Adult. The
Continued Health Care Benefit Program has a quarterly premium.
7. Catastrophic cap
The
catastrophic cap is the most you pay out of pocket each year for
TRICARE covered services. This includes costs, like enrollment fees, deductibles, copayments, and other cost-shares based on the TRICARE-allowable charge. Like the deductible, your catastrophic cap resets each year. Remember that not at all costs apply to the catastrophic cap. These exceptions include:
- Premiums for premium-based plans
- Point-of-service fees for TRICARE Prime
Looking for the specific dollar amounts for these health care terms? Check out the
TRICARE Costs and Fees 2022 Fact Sheet and
TRICARE Compare Cost Tool.
Before you check costs, you’ll want to know if you’re in
Group A or Group B. As described in the
TRICARE Costs and Fees 2022 Fact Sheet, TRICARE beneficiaries fall into one of two groups. Your group determines your enrollment fees or premiums and any other per service out-of-pocket costs that you may have with your health plan.
TRICARE Open Season—the period during which you can choose and enroll in a plan for the next year—is underway until Dec. 13. Understanding
your costs is an important step on the way to choosing the best health plan for you and your family in 2022.